Interspinous process implant having deployable wing and method of implantation

ABSTRACT

Systems and method in accordance with an embodiment of the present invention can includes an implant comprising a first wing, a spacer extending from the first wing, and a distraction guide. The distraction guide is arranged in a first configuration to pierce and/or distract tissue associated with adjacent spinous processes extending from vertebrae of a targeted motion segment. The implant can be positioned between the adjacent spinous processes and once positioned, the implant can be arranged in a second configuration. When arranged in a second configuration, the distraction guide can act as a second wing. The first wing and the second wing can limit or block movement of the implant along a longitudinal axis of the implant.

CLAIM TO PRIORITY

U.S. Provisional Patent Application No. 60/663,918 entitled INTERSPINOUS PROCESS IMPLANT HAVING DEPLOYABLE WING AND METHOD OF IMPLANTATION, by Zucherman et al., filed Mar. 21, 2005 (Attorney Docket No. KLYC-01114US1).

CROSS-REFERENCE TO RELATED APPLICATIONS

This U.S. Provisional Patent Application incorporates by reference all of the following co-pending applications and issued patents:

U.S. Patent Application Ser. No. 60/663,885, entitled “Interspinous Process Implant Having Deployable Wing and Method of Implantation,” (Attorney Docket Number KLYC-01114US0) filed concurrently;

U.S. patent application Ser. No. 10/850,267, entitled “Distractible Interspinous Process Implant and Method of Implantation,” filed May 20, 2004;

U.S. Pat. No. 6,419,676, entitled “Spine Distraction Implant and Method,” issued Jul. 16, 2002 to Zucherman, et al.;

U.S. Pat. No. 6,451,019, entitled “Supplemental Spine Fixation Device and Method,” issued Sep. 17, 2002 to Zucherman, et al.;

U.S. Pat. No. 6,582,433, entitled “Spine Fixation Device and Method,” issued Jun. 24, 2003 to Yun;

U.S. Pat. No. 6,652,527, entitled “Supplemental Spine Fixation Device and Method,” issued Nov. 25, 2003 to Zucherman, et al;

U.S. Pat. No. 6,695,842, entitled “Interspinous Process Distraction System and Method with Positionable Wing and Method,” issued Feb. 24, 2004 to Zucherman, et al;

U.S. Pat. No. 6,699,246, entitled “Spine Distraction Implant,” issued Mar. 2, 2004 to Zucherman, et al; and

U.S. Pat. No. 6,712,819, entitled “Mating Insertion Instruments for Spinal Implants and Methods of Use,” issued Mar. 30, 2004 to Zucherman, et al.

TECHNICAL FIELD

This invention relates to interspinous process implants.

BACKGROUND OF THE INVENTION

The spinal column is a bio-mechanical structure composed primarily of ligaments, muscles, vertebrae and intervertebral disks. The bio-mechanical functions of the spine include: (1) support of the body, which involves the transfer of the weight and the bending movements of the head, trunk and arms to the pelvis and legs, (2) complex physiological motion between these parts, and (3) protection of the spinal cord and the nerve roots.

As the present society ages, it is anticipated that there will be an increase in adverse spinal conditions which are characteristic of older people. By way of example only, with aging comes an increase in spinal stenosis (including, but not limited to, central canal and lateral stenosis), and facet arthropathy. Spinal stenosis results in a reduction foraminal area (i.e., the available space for the passage of nerves and blood vessels) which compresses the nerve roots and causes radicular pain. Humpreys, S. C. et al. Flexion and traction effect on C5-C6 foraminal space, Arch. Phys. Med. Rehabil., vol. 79 at 1105 (September 1998). Another symptom of spinal stenosis is myelopathy, which results in neck and back pain and muscle weakness. Id. Extension and ipsilateral rotation of the neck and back further reduces the foraminal area and contributes to pain, nerve root compression and neural injury. Id.; Yoo, J. U. et al., Effect of cervical spine motion on the neuroforaminal dimensions of human cervical spine, Spine, vol. 17 at 1131 (Nov. 10, 1992). In contrast, neck and back flexion increases the foraminal area. Humpreys, S. C. et al., at 1105.

Over time, loss of disk height in the thoracic and lumbar regions, as well as the cervical region can result in a degenerative cascade with deterioration of all components of a motion segment resulting in segment instability and ultimately in spinal stenosis. During the process of deterioration, disks can become herniated and/or become internally torn and chronically painful. When symptoms seem to emanate from both anterior (disk) and posterior (facets and foramen) structures, patients cannot tolerate positions of extension or flexion.

Pain associated with stenosis can be relieved by medication and/or surgery. It is desirable to eliminate the need for major surgery for all individuals, and in particular, for the elderly.

Accordingly, a need exists to develop spine implants that alleviate pain caused by spinal stenosis and other such conditions caused by damage to, or degeneration of, the spine. Such implants would distract, or increase the space between, the vertebrae to increase the foraminal area and reduce pressure on the nerves and blood vessels of the spine.

A further need exists for development of a minimally invasive surgical implantation method for spine implants that preserves the physiology of the spine.

Further, a need exists for an implant that accommodates the distinct anatomical structures of the spine, minimizes further trauma to the spine, and obviates the need for invasive methods of surgical implantation. Additionally, a need exists to address adverse spinal conditions that are exacerbated by spinal extension.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1A is a perspective view of an implant including a spacer having a tear-drop shaped cross-section, a distraction guide, a first wing, and a second wing connectable with the distraction guide.

FIG. 1B is a perspective view of an implant including a rotatable spacer having an elliptical cross-section, a distraction guide, a first wing, and a second wing connectable with the distraction guide.

FIG. 2A is a perspective view of an implant in accordance with an embodiment of the present invention including a main body and an insert, the main body having a distraction guide, a spacer, and a first wing.

FIG. 2B is a perspective view of the implant of FIG. 2A wherein the insert is positioned within the main body, causing the distraction guide associated with the main body to limit or block movement of the implant when positioned between adjacent spinous processes.

FIG. 3A is a side view of the main body of the implant of FIGS. 2A and 2B positioned between adjacent spinous processes.

FIG. 3B is a side view of the implant of FIG. 3A wherein the insert is positioned within the main body.

FIG. 4 is a perspective view of an implant in accordance with an alternative embodiment wherein the main body includes hooks to limit relative movement of adjacent spinous processes during flexion motion.

FIG. 5 is a side view of the implant of FIG. 4 positioned between adjacent spinous processes and arranged so that the hooks confine the adjacent spinous processes.

FIG. 6A is a perspective view of still another embodiment of an implant in accordance with the present invention, wherein a first section and a second section of a distraction guide are deployable to form a second wing.

FIG. 6B is a perspective view of the implant of FIG. 6A wherein the insert is positioned within the main body, causing the first section and the second section of the distraction guide to deploy.

FIG. 7A is a perspective view of a still further embodiment of an implant in accordance with the present invention including a rotatable spacer.

FIG. 7B is a perspective view of the implant of FIG. 7A wherein the insert is positioned within a central body so that the distraction guide deploys as a second wing.

FIG. 7C is a cross-sectional side view of distraction guide of FIG. 7A.

FIG. 7D is a cross-sectional side view of distraction guide of FIG. 7B.

FIG. 8 is a side view of the implant of FIGS. 7A-7D positioned between adjacent spinous processes.

FIG. 9A is a side view of an alternative embodiment of the implant positioned between adjacent spinous processes.

FIG. 9B is a partial cross-section side view of the implant of FIG. 9A showing deployable winglets disposed within a distraction guide of the implant.

FIG. 9C is a partial cross-sectional side view of the implant of FIG. 9B wherein the winglets deployed.

FIG. 10A is a side view of an alternative embodiment of the implant positioned between adjacent spinous processes.

FIG. 10B is a side view of the implant of FIG. 10A positioned between adjacent spinous processes wherein the winglets deployed.

FIG. 10C is a partial cross-sectional end view of the implant of FIG. 10A showing deployable winglets disposed within a distraction guide of the implant.

FIG. 10D is a partial cross-sectional end view of the implant of FIGS. 10A-10C showing the winglets deployed so that the winglets extend from the distraction guide of the implant.

FIG. 10E is an end view of the implant of FIGS. 10A-10D showing the distraction guide and the deployed winglets relative to the distraction guide.

FIG. 11A is a partial cross-sectional end view of an alternative embodiment of an implant in accordance with the present invention including an alternative actuator arrangement.

FIG. 11B is an partial cross-sectional end view of the implant of FIG. 11A showing the winglets deployed so that the winglets extend from the distraction guide of the implant.

FIG. 12A is a partial cross-sectional end view of still another embodiment of an implant in accordance with the present invention having an alternative actuator arrangement wherein the winglets comprise two hinged portions.

FIG. 12B is a partial cross-sectional end view of the implant of FIG. 12A showing the winglets deployed so that the winglets extend from the distraction guide of the implant.

FIG. 13 is a partial cross-sectional end view of a still further embodiment of an implant in accordance with the present invention wherein implants are arranged at adjacent motion segments.

FIG. 14 illustrates an embodiment of a method for implanting the implant of FIGS. 2A-8 between adjacent spinous processes in accordance with the present invention.

FIG. 15A illustrates an embodiment of a method for implanting the interspinous implant of FIGS. 2A-8 between adjacent spinous processes in accordance with the present invention.

FIG. 15B illustrates an embodiment of a method for implanting the interspinous implant of FIGS. 9A-13 between adjacent spinous processes in accordance with the present invention.

DETAILED DESCRIPTION

Interspinous Implants

FIG. 1A is a perspective view of an implant as described in U.S. patent application Ser. No. 10/850,267, filed May 20, 2004, incorporated herein by reference. The implant 100 comprises a first wing 130, a spacer 120, and a lead-in tissue expander (also referred to herein as a distraction guide) 110. The distraction guide 110 in this particular embodiment is wedge-shaped, i.e., the implant has an expanding cross-section from a proximal end of the implant 100 to a region 150 where the guide 110 joins with the spacer 120 (referencing for the figures is based on the point of insertion of the implant between spinous processes). As such, the distraction guide 110 functions to initiate distraction of the soft tissue and the spinous processes when the implant 100 is surgically inserted between the spinous processes. It is to be understood that the distraction guide 110 can be pointed and the like, in order to facilitate insertion of the implant 100 between the spinous processes of adjacent cervical vertebrae. It is advantageous that the insertion technique disturb as little of the bone and surrounding tissue or ligaments as possible in order to reduce trauma to the site and promote early healing, and prevent destabilization of the normal anatomy. For embodiments such as those of FIGS. 1A and 1B, there is no requirement to remove any of the bone of the spinous processes and no requirement to sever, or remove from the body, ligaments and tissues immediately associated with the spinous processes. For example, it is unnecessary to sever the supraspinal ligament of the lower vertebrae or the ligamentum nuchae (which corresponds to the supraspinal ligament) which partially cushions the spinous processes of the upper cervical vertebrae.

As can be seen, the spacer 120 can be teardrop-shaped in cross-section perpendicular to a longitudinal axis 125 of the implant 100. In this way, the shape of the spacer 120 can roughly conform to a wedge-shaped space, or a portion of the space, between adjacent spinous processes within which the implant 100 is to be positioned. As shown in FIG. 1A, the spacer 120 (and the first wing 108) is shaped to accommodate the anatomical form or contour of spinous processes (and/or laminae) of preferably the C6 and C7 vertebra for placement between such spinous processes (i.e., the C6-C7 motion segment). The same shape or variations of this shape can be used to accommodate other motion segments, for example in the thoracic or lumbar regions. In other embodiments the spacer 120 can have alternative shapes such as circular, wedge, oval, ovoid, football, and rectangular with rounded corners, and other shapes. The shape of the spacer 120 can be selected for a particular patient so that the physician can position the implant 100 as close as possible to the anterior portion of the surface of the spinous process. The shape selected for the spacer 120 can affect the contact surface area of the implant 100 and the spinous processes that are to be subject to distraction. Increasing the contact surface area between the implant 100 and the spinous processes can distribute a load force between the spinous frame and the implant 100.

The first wing 130 is likewise teardrop-shaped in cross-section perpendicular to a longitudinal axis 125 of the spacer 120 and distraction guide 110. The dimensions of the first wing 130 can be larger than that of the spacer 120, particularly along the axis of the spine, and can limit or block lateral displacement of the implant 100 in the direction of insertion along the longitudinal axis 125. As with the spacer 120, the first wing 130 can have other cross-sectional shapes, such as elliptical, wedge, circular, oval, ovoid, football, and rectangular with rounded corners and other shapes.

The implant 100 of FIG. 1A further includes an adjustable wing 160 (also referred to herein as a second wing) separate from the distraction guide 110, the spacer 120 and the first wing 130. The second wing 160 is connectable with the distraction guide 110 (and/or the spacer 120) once the implant 100 is positioned between adjacent spinous processes. The second wing 160, similar to the first wing 130, can limit or block lateral displacement of the implant 100, however displacement is limited or blocked in the direction opposite insertion. When both the first wing 130 and the second wing 160 are connected with the implant 100 and the implant 100 is positioned between adjacent spinous processes, a portion of the spinous processes can be sandwiched between the first wing 130 and the second wing 160, limiting displacement along the longitudinal axis 125. As can be seen, the second wing 160 can be teardrop-shaped in cross-section. A lip 180 defining a space 170 through the second wing 160 allows the second wing 160 to pass over the distraction guide 110 to meet and connect with the distraction guide 110 and/or the spacer 120. The second wing 160 is then secured to the distraction guide 110 and/or the spacer 120. The second wing 160, can be designed to be interference-fit onto the spacer 120 or a portion of the distraction guide 110 adjacent to the spacer 120. Where the second wing 160 is interference-fit, there is no additional attachment device to fasten the second wing 160 relative to the remainder of the implant 100.

Alternatively, various fasteners can be used to secure the second wing 160 relative to the remainder of the implant 100. For example, FIG. 1A illustrates an embodiment of an implant 100 including a teardrop-shaped second wing 160 having a tongue 158 at the posterior end of the second wing 160. A bore 155 is disposed through the tongue 158, and is aligned with a corresponding bore 156 on the spacer 120 when the second wing 160 is brought into position by surgical insertion relative to the rest of the implant 100. A threaded screw 154 can be inserted through the aligned bores 155,156 in a posterior-anterior direction to secure the second wing 160 to the spacer 120. The direction of insertion from a posterior to an anterior direction has the screw 154 engaging the bores 155,156 and the rest of the implant 100 along a direction that is generally perpendicular to the longitudinal axis 125. This orientation is most convenient when the physician is required to use a screw 154 to secure the second wing 160 to the rest of the implant 100. The second wing 160 can further be secured to the spacer 120 by some other mechanism, for example such as a flexible hinge (not shown) with a protrusion that engages an indentation of one of the distraction guide 110 and the spacer 120. Alternatively, the second wing 160 can be secured to one of the distraction guide 110 and the spacer 120 by still some other mechanism.

FIG. 1B is a perspective view of an implant as described in U.S. Pat. No. 6,695,842 to Zucherman, et al., incorporated herein by reference. The implant 200 has a main body that includes a spacer 220, a first wing 230, a lead-in tissue expander 210 (also referred to herein as a distraction guide) and an alignment track 203. The main body of the implant 200 is inserted between adjacent spinous processes and remains in place (where desired) without attachment to the bone or ligaments.

The distraction guide 210 includes a tip from which the distraction guide 210 expands, the tip having a diameter sufficiently small such that the tip can pierce an opening in an interspinous ligament and/or can be inserted into a small initial dilated opening. The diameter and/or cross-sectional area of the distraction guide 210 gradually increases until it is substantially similar to the diameter of the spacer 220. The tapered front end eases the ability of a physician to urge the implant 200 between adjacent spinous processes. When urging the main body of the implant 200 between adjacent spinous processes, the front end of the distraction guide 210 distracts the adjacent spinous processes and dilates the interspinous ligament so that a space between the adjacent spinous processes is approximately the diameter of the spacer 220.

As shown in FIG. 1B, the spacer 220 is elliptically shaped in cross-section, and can swivel so that the spacer 220 can self-align relative to the uneven surfaces of the spinous processes. Self-alignment can ensure that compressive loads are distributed across the surface of the bone. As contemplated in Zucherman '842, the spacer 220 can have, for example, a diameter of six millimeters, eight millimeters, ten millimeters, twelve millimeters and fourteen millimeters. These diameters refer to the height by which the spacer 220 distracts and maintains apart the spinous process. For an elliptically shaped spacer 220, the selected height (i.e., diameter) is the minor dimension measurement across the ellipse. The major dimension is transverse to the alignment of the spinous process, one above the other.

The first wing 230 has a lower portion 231 and an upper portion 232. The upper portion 232 is shaped to accommodate the anatomical form or contour of spinous processes (and/or laminae) of preferably the L4 (for an L4-L5 placement) or L5 (for an L5-S1 placement) vertebra. The same shape or variations of this shape can be used to accommodate other motion segments, such as motion segments in the cervical and thoracic regions. The lower portion 231 can also be rounded to accommodate the spinous processes. The lower portion 231 and upper portion 232 of the first wing 230 act as a stop mechanism when the implant 200 is inserted between adjacent spinous processes. The implant 200 cannot be inserted beyond the surfaces of the first wing 230. Additionally, once the implant 200 is inserted, the first wing 230 can prevent some side-to-side, or posterior-to-anterior movement of the implant 200.

As with the implant 100 of FIG. 1A, the implant 200 of FIG. 1B further includes a second wing 260. Similar to the first wing 230, the second wing 260 includes a lower portion 261 and an upper portion 262 sized and/or shaped to accommodate the anatomical form or contour of the spinous processes and/or lamina. The second wing 260 can be secured to the main body of the implant 200 with a fastener 254. The second wing 260 also has an alignment tab 268. When the second wing 260 is initially placed on the main body of the implant 200, the alignment tab 268 engages the alignment track 203. The alignment tab 268 slides within the alignment track 203 and helps to maintain the adjustable wing 260 substantially parallel with the first wing 230. When the main body of the implant 200 is inserted into the patient and the second wing 260 has been attached, displacement along the longitudinal axis 225 in either the direction of insertion or the direction opposite insertion can be limited or blocked. Further, the second wing 260 also can prevent some side-to-side, or posterior-to-anterior movement.

For both the implant 100 of FIG. 1A and the implant 200 of FIG. 1B, where a second wing 160,260 is connected with the implant 100,200 after the implant 100,200 is positioned between the spinous processes, a procedure for positioning such an implant 100,200 and subsequently connecting the second wing 160,260 with the implant 100,200 can require a bilateral approach wherein a physician must access both sides of the interspinous ligament, a first side to pierce and/or distract the interspinous ligament and position the implant 100,200 so that the movement in the direction of insertion is satisfactorily limited by the first wing 130,230, and a second side to attach the second wing 160,260 such that movement in the direction opposite insertion is satisfactorily limited by the second wing 160,260.

Implants Having Deployable Second Wing

Referring to FIGS. 2A through 3B, implants 300 and methods for positioning such implants in accordance with the present invention can, in an embodiment, include a deployable second wing 360 associated with a main body 301 such that the second wing 360 can be deployed with a physician needing only to access a first side of spinous processes to limit or block movement along the longitudinal axis 325.

As shown in FIG. 2A, the implant 300 includes a main body 301 having a fixed spacer 320 and a distraction guide 310. The distraction guide 310 comprises a first winglet (also referred to herein as an upper winglet) 312 and a second winglet (also referred to herein as a lower winglet) 314, and when arranged in a first configuration can include a tip from which the distraction guide 310 expands, the tip having a diameter sufficiently small such that the tip can pierce an opening in an interspinous ligament and between spinous processes and/or can be inserted into a small initial dilated opening. The diameter and/or cross-sectional area of the distraction guide 310 is then gradually increased until it is substantially similar to the diameter of the spacer 320. In this respect, the distraction guide 310 of FIG. 2A can resemble a distraction guide as described above when arranged in the first configuration. The winglets 312,314 can be hinged or otherwise pivotably connected with the main body 301 such that the winglets 312,314 can be arranged in a second configuration (FIG. 2B) once the implant 300 is positioned between spinous processes. In a second configuration one or both of the winglets 312,314 abut at least one of the spinous processes and/or related tissues when urged in a direction opposite from insertion, thereby limiting motion along the longitudinal axis 325. Thus when arranged in a second configuration, the distraction guide 310 becomes a second wing 360, as shown in FIG. 2B.

The implant 300 includes an insert 370 having an insert body 372 and a first wing 330. As shown in FIG. 2B, the insert 370 can be mated with the main body 301 to arrange the distraction guide 310 of the implant 300 in the second configuration, thereby deploying the second wing 360. To facilitate mating of the main body 301 and the insert 370, the spacer 320 includes a cavity sized and shaped for receiving the insert body 372 and accessible from a distal end of the main body 301. A portion of the upper winglet 312 and the lower winglet 314 can extend at least partially into the cavity so that when the insert body 372 is received within the cavity, the insert body 372 displaces the portions, causing the distraction guide 310 to be arranged in the second configuration. In the embodiment shown, the upper winglet 312 and the lower winglet 314 each include a lever 316,318 comprising a curved protrusion that protrudes into the cavity when the distraction guide 310 is in the first configuration. As the insert body 372 of the insert 370 fills the cavity, the insert body 372 contacts the first lever 316 and the second lever 318, applying a force to the first lever 316 and the second lever 318 which translates into a pivoting motion of the hinged upper winglet 312 and the hinged lower winglet 314. The insert body 372 can optionally have a tapered proximal end 374 having a first groove 376 and a second groove 378 corresponding to the first lever 316 and the second lever 318, respectively. The tapered shape of the proximal end 374 allows the upper winglet 312 and lower winglet 314 to be deployed gradually, fully deploying as the insert body 372 is fully seated within the cavity. The main body 301 is shown including a flange 303 in which is formed notches 305 to receive an insertion tool (not shown), for example. As the insert body 372 is seated within the cavity, an upper tab 332 and a lower tab 331 of the first wing 330 seats within cut-outs 322 of the flange 303.

Referring to FIG. 3A, the main body 301 of the implant 300 is shown positioned between adjacent spinous processes of the targeted motion segment. The motion segment shown is within the lumbar region, but in other embodiments, particularly where a fixed spacer 320 is used, implants 300 in accordance with the present convention can be positioned at motion segments of the thoracic and cervical region. The main body 301 is positioned as shown by initially approaching the interspinous ligament between the upper and lower adjacent spinous processes 2,4 through an opening to the right of the interspinous ligament, roughly posterior to the right inferior articular facet 6 of the vertebrae from which the upper spinous process 2 extends. The main body 301 can be associated with one or more insertion tools (not shown), and the distraction guide 310 can be arranged in the first configuration. The tip of the distraction guide 310 is positioned roughly adjacent to a point along the interspinous ligament, and the distraction guide 310 is then urged through the interspinous ligament, piercing the interspinous ligament and/or separating and distracting fibers of the interspinous ligaments. The main body 301 is then urged through the interspinous ligament until the spacer 320 is positioned between the adjacent spinous processes 2,4 so that the spacer 320 supports a load applied by the spinous processes 2,4.

Referring to FIG. 3B, once the implant 300 is positioned as desired, the insertion tools can be removed from the opening and the insert 370 can be positioned at the distal end of the main body 301. The insert body 372 can be urged into the cavity within the main body 301 until the proximal end 374 of the insert body 372 contacts the first lever 316 and the second lever 318. The insert 370 can then be further urged along the longitudinal axis 325 so that the insert body 372 urges the first lever 316 and the second lever 318 away from the insert body 372, causing the upper winglet 312 and the lower winglet 314 to pivot about the first hinge 313 and the second hinge 315, respectively. As the first lever 316 and the second lever 318 are displaced from the cavity, the first lever 316 and the second lever 318 are guided along corresponding grooves 376,378 of the tapered proximal end 374. As the insert body 372 seats within the cavity of the main body 301, the upper winglet 312 and the lower winglet 314 deploy as a second wing 360. The insertion tool can be removed from the incision once the insert body 372 is seated within the main body 301. As can be seen a portion of the upper spinous process and a portion of the lower spinous process are sandwiched between the first wing 330 and the second wing 360, limiting motion along the longitudinal axis 325.

Implants and methods for positioning such implants between spinous processes in accordance with the present invention are not meant to be limited to embodiments as described above and otherwise herein, but rather are meant to include any implant having a second wing deployable by urging an insert within a main body positioned between adjacent spinous processes. Myriad different variations may be readily apparent to one of ordinary skill in the art. For example, in an alternative embodiment, the main body 301 of the implant 300 of FIGS. 2A through 3B can include a lower winglet 314 pivotably associated with the main body 301 while an upper winglet 312 is fixedly associated with the main body 301. An insert 370 can be adapted to deploy only the lower winglet 314 when seated within the cavity of the main body 301.

In other embodiments, a first wing 310 can extend from the main body 301 rather than, or in addition to, a first wing extending from the insert 370. When the main body 301 is initially positioned between the adjacent spinous processes, movement of the main body 301 along the longitudinal axis 325 can be limited in the direction of insertion. As the first wing 310 extending from the main body 301 contacts one or both of the adjacent spinous processes, further movement of the main body 301 in the direction of insertion can be limited or blocked. The first wing 310 can thus act as a hard stop, allowing the main body 301 to be positioned without requiring a position of the main body 301 along the spinous processes to be estimated, thereby easing implantation.

Referring to FIG. 4, in still further embodiments implants 400 in accordance with the present invention can include one or both of a first engagement element (also referred to herein as an upper hook) 480 and a second engagement element (also referred to herein as a lower hook) 482 for limiting flexion motion in a motion segment. For example, similar hooks have been described in greater detail in U.S. Pat. No. 6,451,019 issued Sep. 17, 2002 to Zucherman et al. and U.S. Pat. No. 6,652,527 issued Nov. 25, 2003 to Zucherman et al., both incorporated herein by reference. Implants in accordance with the present invention can include such arrangements. The implant 400 shown in FIGS. 4 and 5 includes an upper hook 480 extending from an upper connection rod 484 rotatably associated with the main body 401 and a lower hook 482 extending from a lower connection rod 486 rotatably associated with the main body 401. Alternatively, the connection rods 484,486 can be fixedly associated with the main body 401. The hooks 480,482 include tapered proximal ends 481,483 that act as lead-in tissue expanders to distract interspinous ligaments of the motion segments above and below the targeted motion segment. As the main body 401 is positioned between adjacent spinous processes, the tapered proximal ends 481,483 of the upper and lower hooks 480,482 can likewise pierce and/or distract interspinous ligaments so that the upper and lower hooks 480,482 can be properly positioned to limit or restrain flexion motion of the targeted motion segment when the main body 401 is in place. As shown, the hooks 480,482 can be pivotably associated with the connection rods 484,486 so that the hooks 480,482 can be rotated relative to the connection rods 484,486, thereby allowing a physician to improve contact and spread loads between the hooks 480,482 and corresponding spinous processes 2,4. The rotatable upper connection rod 484 and lower connection rod 486 can provide flexibility in placement, so that where an anatomy varies between patients and varies between motion segments such that the arrangement of a minor dimension and major dimension of the implant 400 about the longitudinal axis 425 varies, the implant 400 can be accommodated.

FIG. 5 is a posterior view of the implant 400 positioned between adjacent spinous processes 2,4 and having an upper hook 480 and a lower hook 482 arranged so that both flexion and extension is limited as desired. Further, the second wing 460 is deployed to limit movement of the implant 400 along the longitudinal axis 425. The upper hook 480 and the lower hook 482 prevent movement along the longitudinal axis 425 in the direction opposite insertion, making a first wing unnecessary.

Referring to FIGS. 6A and 6B, in still other embodiments implants 500 and methods for positioning such implants 500 between spinous processes in accordance with the present invention can include a distraction guide 510 wherein portions of the distraction guide 510 can be extended from the distraction guide 510 to form an upper winglet 512 and a lower winglet 514, respectively, of a second wing 560 by positioning an insert 570 within a cavity of the main body 501. This is in contrast to the above embodiment where the entire distraction guide is formed by the winglets. In this embodiment, the winglet 512,514 extend out the side of the distraction guide 510. When not extended, as seen in FIG. 6A, the winglet 512,514 partially form the sides of the distraction guide 510. Such embodiments are contemplated to be useful where it is desired that the second wing 560 have a limited height relative to implants 300,400 as described above where the entire distraction guide 310 is deployed (see FIG. 2A through 3B). For example, where implants 500 are to be positioned at adjacent motion segments, it can be desired that the second wings 560 of the implants 500 do not interfere with one another implant, for example during an extension motion when compressive loads are applied to the implants 500. As with implants described above, one of ordinary skill in the art can appreciate the myriad different variations of the implant 500 of FIGS. 6A and 6B. For example, in alternative embodiments the upper winglet 512 and the lower winglet 514 can have some other shape. For example, the positions of the upper winglet 512 and lower winglet 514 are staggered so that implants 500 positioned at adjacent motion segments can be more easily positioned without interfering with one another. Such staggering can also accommodate anatomies where one of the upper and lower spinal processes is wider than the other. With staggering, for example, the upper winglet 512 can be pivotably mounted on the distraction guide 510 at a position less distant from the distraction end 511 than the location where the lower winglet 514 is pivotably mounted on the distraction guide 510. In still other embodiments, the upper winglet 512 and the lower winglet 514 can have some other shape.

Referring to FIGS. 7A through 8, in still further embodiments of implants 600 in accordance with the present invention, the main body 601 can include a hollow central body 605 (shown in FIGS. 7C and 7D) extending from a first wing 630. A rotatable spacer 620 is disposed about the hollow central body 605. The implant 600 can include a spacer 620 that resembles spacers, for example, as described above in FIG. 1B. A distraction guide 610 can extend from the hollow central body 605 and can include an upper winglet 612 and a lower winglet 614, one or both of which can be pivotably associated with a main portion 611 of the distraction guide 610 so that the upper winglet 612 and/or the lower winglet 614 can be deployed as a second wing 660. A pin 606 can be inserted into the hollow central body 605 to deploy the second wing 630. Referring to FIG. 7B, once the pin 606 is seated within the main body 601, the upper winglet 612 and the lower winglet 614 can be pivoted away from each other so that the upper winglet 612 and the lower winglet 614 limit or block motion along the longitudinal axis 625 in the direction opposite from insertion. The upper winglet 612 and the lower winglet 614 thus act as a second wing 660. Referring to the partial cross-sections of FIGS. 7C and 7D, in an embodiment the distraction guide 610 can include a cup 616 structure sized and arranged to receive the pin 606. Bar structures 618,619 can be pivotably connected between the cup structure 616 and one or both of the upper winglet 612 and the lower winglet 614 so that when a force is applied to the cup structure 616 by the pin 606, the force is further transferred to the upper winglet 612 and the lower winglet 614, causing the upper winglet 612 and the lower winglet 614 to pivot on hinges 613,615 associated with the main portion 611 of the distraction guide 610 so that the second wing 660 is deployed. As can be seen, the pivot points 613,615 of the upper winglet 612 and the lower winglet 614 are arranged proximally relative to the mount points 617,619 of the bar structures 618,619, causing the upper winglet 612 and the lower winglet 614 to pivot away from one another when the mount points 617,619 are urged together by the insertion of the pin 606 (as seen in FIG. 7D). In other embodiments, the upper winglet 612 and the lower winglet 614 can be caused to pivot away from one another using some other mechanism. Implants in accordance with the present invention are not intended to be limited to such second wing deployment mechanisms as are described in detail herein.

Referring to FIG. 8, the implant 600 is shown positioned between adjacent spinous processes 2,4. The second wing 660 as shown is sized such that when arranged in a first configuration (i.e., as a distraction guide 610) the upper winglet 612 and the lower winglet 614 do not extend undesirably into the adjacent tissues. However, the upper winglet 612 and the lower winglet 614 can be sized and shaped other than as shown in FIG. 8. The upper winglet 612 and the lower winglet 614 need only be sized and shaped such that when arranged in a second configuration, the upper and lower winglets 612,614 limit or block movement along the longitudinal axis 625 in a direction opposite from insertion.

FIGS. 9A through 9C illustrate a further embodiment of an implant 700 in accordance with the present invention arranged between adjacent spinous processes 2,4. In such an embodiment, upper and lower winglets 712,714 can be disposed within the distraction guide 710 and can be deployed by actuating an actuator arrangement including a shaft connected with a cam 707, the shaft having an engageable head 706, or alternatively including some other mechanism such as a gear. As can be seen in FIG. 9A the implant 700 can be disposed between adjacent spinous processes 2,4 as described above in reference to FIG. 3. The distraction guide 710 of the implant 700 can be employed to pierce and/or distract an interspinous ligament 6 connected between the adjacent spinous process 2,4. The implant 700 can then be urged between the spinous processes 2,4 so that the distraction guide 710 further distracts the interspinous ligament 6 to form a space within which a spacer 220 can be disposed. In the embodiment shown, the spacer 220 can pivot about a central body extending from the first wing 230 of the implant 700. The first wing 230 limits and/or blocks movement along a longitudinal axis 725 of the implant 700 in the direction of insertion.

Once the implant 700 is arranged as desired, the actuator arrangement can be actuated to deploy the upper and lower winglets, 712,714, thereby forming a second wing 760 as shown in FIG. 9C. The second wing 760 limits and/or blocks movement along the longitudinal axis 725 in a direction opposite the direction of insertion. With the second wing 760 deployed, the adjacent spinous processes 2,4 are at least partially disposed between the wings 730,760, preventing the implant 800 from becoming undesirably dislodged from the space between the adjacent spinous processes 2,4. As shown in FIG. 9C, the first wing 730 and the second wing 760 can be arranged sufficiently far apart that the adjacent spinous processes 2,4 can move relative to one another slightly (e.g., laterally—such as during a twisting motion), allowing the patient greater flexibility of movement.

FIGS. 9B and 9C are partial cross-sectional posterior views of the implant 700 shown in FIG. 9A. In an embodiment, the deployable winglets 712,714 can be extended from the distraction guide 710 using an actuator arrangement comprising a shaft 707 and cam 716. The cam 716 can be rotated to force the winglets 712,714 to pivot outward from the distraction guide 710. As shown, the winglets 712,714 are at least partially disposed within a cavity of the distraction guide 710.

FIGS. 10A through 10E illustrate a still further embodiment of an implant 800 in accordance with the present invention arranged between adjacent spinous processes 2,4. In such an embodiment, upper and lower winglets 812,814 can be disposed within the distraction guide 810 and can be deployed by actuating an actuator arrangement including a screw 807 having an engageable head 806, or alternatively including some other mechanism such as a gear. As can be seen in FIG. 10A the implant 800 can be disposed between adjacent spinous processes 2,4 as described above in reference to FIG. 3. The distraction guide 810 of the implant 800 can be employed to pierce and/or distract an interspinous ligament 6 connected between the adjacent spinous process 2,4. The implant 800 can then be urged between the spinous processes 2,4 so that the distraction guide 810 further distracts the interspinous ligament 6 to form a space within which a spacer 220 can be disposed. In the embodiment shown, the spacer 220 can pivot about a central body extending from the first wing 230 of the implant 800. The first wing 230 limits and/or blocks movement along a longitudinal axis 825 of the implant 800 in the direction of insertion.

Once the implant 800 is arranged as desired, the actuator arrangement can be actuated to deploy the upper and lower winglets, 812,814, thereby forming a second wing 860 as shown in FIG. 9B. The second wing 860 limits and/or blocks movement along the longitudinal axis 825 in a direction opposite the direction of insertion. With the second wing 860 deployed, the adjacent spinous processes 2,4 are at least partially disposed between the wings 830,860, preventing the implant 800 from becoming undesirably dislodged from the space between the adjacent spinous processes 2,4. As shown in FIG. 9B, the first wing 830 and the second wing 860 can be arranged sufficiently far apart that the adjacent spinous processes 2,4 can move relative to one another slightly (e.g., laterally—such as during a twisting motion), allowing the patient greater flexibility of movement.

FIGS. 10C and 10D are partial cross-sectional end views of the implant 800 shown in FIGS. 10A and 10B. In an embodiment, the deployable winglets 812,814 can be extended from the distraction guide 810 using an actuator arrangement comprising a screw 806 and threaded collar 816. The threaded collar 816 can be driven along the screw 806 to force the winglets 812,814 to pivot outward from the distraction guide 810. As shown, the winglets 812,814 are at least partially disposed within a cavity of the distraction guide 810. The winglets 812,814 are pivotably connected with the threaded collar 816 at an upper pivot point 817 and a lower pivot point 819. Pins 813,815 or other obstruction devices can be disposed within the cavity and arranged so that the pins 813,815 do not interfere with the arrangement of the winglets 812,814 in a nested, or undeployed, position. However, as the threaded collar 816 travels along the screw 806 in a posterior-to-anterior direction, the inner surface of the winglets 812,814 contact the pins 813,815 and the winglets 812,814 pivot away from the distraction guide 810. If desired the winglets 812,814 can be spring biased against the posts 813,815 such that in the nested positions and in any deployed position the winglets 812,814 are held against the posts 813,815.

As shown in FIGS. 10D and 10E, when the threaded collar 816 has traveled a distance along the screw 806, the winglets 812,814 are deployed to form a second wing 860. The winglets 812,814 extend along a significant portion of the outer surface of the spinous processes 2,4. When urged along the longitudinal axis 825 in a direction opposite the direction of insertion, the winglets 812,814 contact the adjacent spinous processes 2,4 and resist further movement in said direction. FIG. 10E is an end view of the implant 800 with the second wing 860 deployed. As shown, the screw head 806 extends from the distraction guide 810; however, when implemented, it is preferable for the screw head 806 to be either flush with the surface of the distraction guide 810 or slightly receded from the surface of the distraction guide 810 so that movement of the implant 800 is not obstructed during distraction of the interspinous ligament 6 and/or the spinous processes 2,4. The screw head 806 is shown extending from the distraction guide 810 to demonstrate possible arrangement relative to the proximal end of the distraction guide 810.

FIGS. 11A and 11B illustrate yet another embodiment of the implant 900 having an alternative actuation arrangement. In such an embodiment, the winglets 912,914 can be reversed in arrangement so that the winglets 912,914 are deployed by urging the threaded collar 916 toward the screw head 806. FIGS. 12A and 12B illustrate a still further embodiment of the implant 1000 having an alternative actuation arrangement. In such embodiments, the winglets 1012,1014 include two hinged portions, each winglet 1012,1014 folding outward to form a portion of a second wing 1060. The second wing 1060 does not extend as far along the axis of the spine, i.e. the total height of the second wing 1060 along the spine is smaller than previous embodiments. A reduced second wing height can be advantageous where implants are positioned at adjacent motion segments, thereby preventing undesired contact of adjacent implants.

As mentioned above, in other embodiments in accordance with the present invention, the winglets can be deployed from the distraction guide using a mechanism other than a screw and threaded collar. For example, one or more gears can be employed. Further, in still other embodiments the upper and lower winglets can have a shape along other than those shapes shown in FIGS. 10A through 12B. The invention is not intended to be limited to winglets having shapes such as shown. In still further embodiments, such as shown in FIG. 13, the implant 1100 can include only one of the upper and lower winglets. For example, where implants are positioned at adjacent motion segments it can be advantageous to have a lower winglet 814, thereby preventing undesired contact of adjacent implants 1100. As will be obvious to one of ordinary skill in the art, myriad different actuation arrangements can be employed to form a second wing. Implants in accordance with the present invention are not intended to be limited to those described in detail herein.

Materials for Use in Implants of the Present Invention

In some embodiments, the implant, and components of the implant (i.e., the spacer, the distraction guide, etc.) can be fabricated from medical grade metals such as titanium, stainless steel, cobalt chrome, and alloys thereof, or other suitable implant material having similar high strength and biocompatible properties. Additionally, the implant can be at least partially fabricated from a shape memory metal, for example Nitinol, which is a combination of titanium and nickel. Such materials are typically radiopaque, and appear during x-ray imaging, and other types of imaging. Implants in accordance with the present invention, and/or portions thereof can also be fabricated from somewhat flexible and/or deflectable material. In these embodiments, the implant and/or portions thereof can be fabricated in whole or in part from medical grade biocompatible polymers, copolymers, blends, and composites of polymers. A copolymer is a polymer derived from more than one species of monomer. A polymer composite is a heterogeneous combination of two or more materials, wherein the constituents are not miscible, and therefore exhibit an interface between one another. A polymer blend is a macroscopically homogeneous mixture of two or more different species of polymer. Many polymers, copolymers, blends, and composites of polymers are radiolucent and do not appear during x-ray or other types of imaging. Implants comprising such materials can provide a physician with a less obstructed view of the spine under imaging, than with an implant comprising radiopaque materials entirely. However, the implant need not comprise any radiolucent materials.

One group of biocompatible polymers is the polyaryletherketone group which has several members including polyetheretherketone (PEEK), and polyetherketoneketone (PEKK). PEEK is proven as a durable material for implants, and meets the criterion of biocompatibility. Medical grade PEEK is available from Victrex Corporation of Lancashire, Great Britain under the product name PEEK-OPTIMA. Medical grade PEKK is available from Oxford Performance Materials under the name OXPEKK, and also from CoorsTek under the name BioPEKK. These medical grade materials are also available as reinforced polymer resins, such reinforced resins displaying even greater material strength. In an embodiment, the implant can be fabricated from PEEK 450G, which is an unfilled PEEK approved for medical implantation available from Victrex. Other sources of this material include Gharda located in Panoli, India. PEEK 450G has the following approximate properties:

Property Value Density 1.3 g/cc Rockwell M  99 Rockwell R 126 Tensile Strength  97 MPa Modulus of Elasticity 3.5 GPa Flexural Modulus 4.1 GPa PEEK 450G has appropriate physical and mechanical properties and is suitable for carrying and spreading a physical load between the adjacent spinous processes. The implant and/or portions thereof can be formed by extrusion, injection, compression molding and/or machining techniques.

It should be noted that the material selected can also be filled. Fillers can be added to a polymer, copolymer, polymer blend, or polymer composite to reinforce a polymeric material. Fillers are added to modify properties such as mechanical, optical, and thermal properties. For example, carbon fibers can be added to reinforce polymers mechanically to enhance strength for certain uses, such as for load bearing devices. In some embodiments, other grades of PEEK are available and contemplated for use in implants in accordance with the present invention, such as 30% glass-filled or 30% carbon-filled grades, provided such materials are cleared for use in implantable devices by the FDA, or other regulatory body. Glass-filled PEEK reduces the expansion rate and increases the flexural modulus of PEEK relative to unfilled PEEK. The resulting product is known to be ideal for improved strength, stiffness, or stability. Carbon-filled PEEK is known to have enhanced compressive strength and stiffness, and a lower expansion rate relative to unfilled PEEK. Carbon-filled PEEK also offers wear resistance and load carrying capability.

As will be appreciated, other suitable similarly biocompatible thermoplastic or thermoplastic polycondensate materials that resist fatigue, have good memory, are flexible, and/or deflectable, have very low moisture absorption, and good wear and/or abrasion resistance, can be used without departing from the scope of the invention. As mentioned, the implant can be comprised of polyetherketoneketone (PEKK). Other material that can be used include polyetherketone (PEK), polyetherketoneetherketoneketone (PEKEKK), polyetheretherketoneketone (PEEKK), and generally a polyaryletheretherketone. Further, other polyketones can be used as well as other thermoplastics. Reference to appropriate polymers that can be used in the implant can be made to the following documents, all of which are incorporated herein by reference. These documents include: PCT Publication WO 02/02158 A1, dated Jan. 10, 2002, entitled “Bio-Compatible Polymeric Materials;” PCT Publication WO 02/00275 A1, dated Jan. 3, 2002, entitled “Bio-Compatible Polymeric Materials;” and, PCT Publication WO 02/00270 A1, dated Jan. 3, 2002, entitled “Bio-Compatible Polymeric Materials.” Other materials such as Bionate®, polycarbonate urethane, available from the Polymer Technology Group, Berkeley, Calif., may also be appropriate because of the good oxidative stability, biocompatibility, mechanical strength and abrasion resistance. Other thermoplastic materials and other high molecular weight polymers can be used.

Methods for Implanting Interspinous Implants

A minimally invasive surgical method for implanting an implant 300 as shown in FIGS. 2A-8 in the cervical spine is disclosed and taught herein. In this method, as shown in FIG. 14, preferably a guide wire 780 is inserted through a placement network 790 into the neck of the implant recipient. The guide wire 780 is used to locate where the implant 300 is to be placed relative to the cervical spine, including the spinous processes. Once the guide wire 780 is positioned with the aid of imaging techniques, an incision is made on the side of the neck so that an implant 300 in accordance with an embodiment of the present invention, can be positioned in the neck thorough an incision and along a line that is about perpendicular to the guide wire 780 and directed at the end of the guide wire 780. The main body 301 of the implant 300 is inserted into the neck of the patient. Preferably during insertion, the distraction guide 310 pierces or separates the tissue without severing the tissue.

Once the main body 301 is satisfactorily positioned, an insert 370 can be positioned within a cavity of the main body 301, causing the distraction guide 310 of the main body 301 to be arranged in a second configuration so that at least a portion of the distraction guide 310 forms a second wing. The insert 370 can be inserted along a line that is generally colinear with the line over which the main body 301 is inserted. The anatomy of the neck is such that it is most convenient and minimally invasive to enter the neck from the side with respect to the main body 301 and the insert 370.

Further, a minimally invasive surgical method for implanting an implant as described in FIGS. 2A-8 in the lumbar spine is disclosed and taught herein. In this method, as shown in the flowchart of FIG. 15A, preferably a unilateral incision or opening can be made using a posterior-anterior approach (Step 102). The unilateral incision can be made, for example, at a location some distance to the left of an axis along the spinous process. The incision or opening can be enlarged, and a distraction tool can be positioned within the incision so that the proximal end of the distraction tool (Step 104) can access an exposed side of the interspinous ligament. The distraction tool can be urged through the interspinous ligament, thereby distracting the interspinous ligament so as to receive the implant (Step 106). Once the interspinous ligament is sufficiently distracted, the distraction tool can be disengaged and removed from the incision (Step 108).

Once the distraction tool has been removed from the incision, the implant can be positioned at the dilated opening, and the distraction guide of the implant can be urged through the dilated opening (Step 110). The implant can be further urged through the opening until the spacer is positioned as desired between the adjacent spinous processes of the targeted motion segment (Step 112). The spacer is free to rotate so that the load is distributed more evenly over the surface of the spinous processes. Optionally, the implant can be urged through the dilated opening until the first wing contacts the adjacent spinous processes, thereby blocking further movement in the direction of insertion. Once the implant is properly arranged, the insert can be positioned at the distal end of the implant so that the insert can be urged into and through the hollow cavity of the hollow central body (Step 114). As the insert is seated inside of the cavity, the distraction guide splits, and the upper winglet and the lower winglet deploy as a second wing. The remaining tools can be removed from the incision, and the incision can be closed (Step 116). Preferably during insertion, the distraction end pierces or separates the tissue without severing the tissue.

Further, a minimally invasive surgical method for implanting an implant as shown in FIGS. 9A-13 in the lumbar spine is disclosed and taught herein. In this method, as shown in the flowchart of FIG. 15B, an incision or opening can be made using a posterior-anterior approach (Step 202). The incision or opening can be enlarged, and a distraction tool can be positioned within the incision so that the proximal end of the distraction tool (Step 204) can access an exposed side of the interspinous ligament. The distraction guide can be urged through the interspinous ligament and distracted, thereby distracting the interspinous ligament so as to receive the implant (Step 206). Once the interspinous ligament is sufficiently distracted, the distraction tool can be disengaged and removed from the incision (Step 208).

Once the distraction guide has been removed from the incision, the implant can be positioned at the dilated opening, and the distraction guide of the implant can be urged through the dilated opening (Step 210). The implant can be further urged through the opening until the spacer is positioned as desired between the adjacent spinous processes of the targeted motion segment (Step 212). The spacer is free to rotate so that the load is distributed more evenly over the surface of the spinous processes. Optionally, the implant can be urged through the dilated opening until the first wing contacts the adjacent spinous processes, thereby blocking further movement in the direction of insertion. Once the implant is properly arranged, an actuation tool can be inserted within the incision at an opposite side of the adjacent spinous processes from the point of insertion (Step 214). The actuation tool can engage the actuation arrangement, and can actuate the actuation arrangement so that the upper winglet and the lower winglet deploy as a second wing, as described above (Step 216). The remaining tools can be removed from the incision, and the incision can be closed (Step 218). Preferably during insertion, the distraction end pierces or separates the tissue without severing the tissue.

The foregoing description of the present invention have been presented for purposes of illustration and description. It is not intended to be exhaustive or to limit the invention to the precise forms disclosed. Many modifications and variations will be apparent to practitioners skilled in this art. The embodiments were chosen and described in order to best explain the principles of the invention and its practical application, thereby enabling others skilled in the art to understand the invention for various embodiments and with various modifications as are suited to the particular use contemplated. It is intended that the scope of the invention be defined by the following claims and their equivalents. 

1.-18. (canceled)
 19. A distractor instrument, comprising: a first distractor member that engages at a distal end to a first skeletal segment; a second distractor member that engages at a distal to a second skeletal segment; a distractor device mounted to proximal ends of the first and second distractor members; a distraction actuator attached to the distractor device, wherein the distraction actuator is actuated to apply a distraction force to the first and second distractor members to distract the first and second skeletal segments relative to one another.
 20. An instrument as in claim 19, further comprising a force indicator attached to the distractor device wherein the force indicator provides measurement of the distraction force.
 21. An instrument as in claim 19, further comprising a localizing needle that attaches to the distractor device, wherein the localizing needle has a distal end that points to a target location for positioning an implant.
 22. An instrument as in claim 19, further comprising an insertion device pivotably attached to the distractor device, wherein the insertion device is pivotable to an orientation so as to deliver an object into a targeted space.
 23. An instrument as in claim 22, wherein the insertion device includes a connector portion and a curved portion, wherein the connector portion extends outwardly from the distractor device, and wherein the curved portion has a radius of curvature substantially equal to a distance defined by of the connector portion.
 24. An instrument as in claim 23, wherein the insertion device pivots about a pivot axis such that a distal end of the curved portion pivots toward the targeted space.
 25. An instrument as in claim 22, further comprising a trocar removably and slidably positioned inside the insertion device, the trocar having a sharpened tip.
 26. An instrument as in claim 19 wherein the first and second distractor members each comprises an anchor that penetrates into the skeletal segment and an elongate sheath positioned over the anchor.
 27. An instrument as in claim 22, wherein the insertion device has a guide shaft, and wherein the insertion device is pivotable to an orientation such that the guide shaft provides a passageway for the delivery of an orthopedic device into the space between the pair of skeletal segments.
 28. An instrument as in claim 22, wherein the insertion device has a solid guide shaft and wherein the object is attached to a distal end of the guide shaft.
 29. An instrument as in claim 19, further comprising: a localizing needle that attaches to the distractor device, wherein the localizing needle has a distal end that points to a target location for positioning an implant; and an insertion device pivotably attached to the distractor device, wherein the insertion device has a delivery end that pivots to the target location for delivery an object to the target location.
 30. An instrument as in claim 22, further comprising a sizing device that couples to the insertion device, wherein the sizing device provides an indication as to the size the space between the skeletal segments, the sizing device including a tapered region that can be inserted into the space.
 31. An instrument as in claim 30, wherein the sizing instrument reduces a distractor load on the distractor device as the sizing instruments is inserted into the space wherein reducing a load of the distractor device serves as a confirmation that the sizing instrument is properly positioned to measure a size of an object to be inserted into the space.
 32. A distractor instrument, comprising: first and second distraction members that each engage a respective skeletal segment, wherein the distraction members can be distracted to cause distraction of the skeletal segments.
 33. An instrument as in claim 32, wherein at least one of the distractor members is an anchor that penetrates into a skeletal segment.
 34. An instrument as in claim 32, wherein at least one of the distractor members is an elongate member that abuts a skeletal segment but does not penetrate the skeletal segment.
 35. An instrument as in claim 32, wherein at least one of the distractor members clamps onto the skeletal segment.
 36. An instrument as in claim 32, further comprising a distraction device connected to the distractor members for applying a distraction force to the distractor members.
 37. An instrument as in claim 36, further comprising a measurement device for measuring the distractor force.
 38. A method of distracting a pair of spinous processes, comprising: using one or more distractor elements to engage the spinous processes to apply a distraction force to the spinous processes.
 39. A method as in claim 38, wherein at least one of the distractor elements penetrates a vertebral body.
 40. A method as in claim 38, wherein at least one of the distractor elements abuts a spinous process without penetrating the spinous process.
 41. A minimally-invasive surgical procedure, comprising: localizing a surgical point of interest using a localizing needle that points to the point of interest; and placing an implant at the point of interest using the localizing needle as a guide.
 42. A procedure as in claim 41, wherein the implant is placed using an inserter device that pivots about a central axis such that the inserter device travels along a curvilinear path that contains the localized point of interest.
 43. A minimally-invasive surgical procedure, comprising: localizing a surgical point of interest using an x-ray to identify the point of interest; relating the point of interest to a delivery apparatus; and delivering an implant to the point of interest using an inserter device that pivots about a central axis such that the inserter device travels along a curvilinear path that contains the localized point of interest.
 44. A skeletal implant holder, comprising: a hand-operated handle assembly; a holder assembly attached to the handle assembly, the holder assembly configured to be removably attached to an implant, wherein the handle assembly can be actuated to secure the implant to the holder assembly and to detach the implant from the holder assembly, and wherein the holder assembly is configured to apply a first force to the implant in a first direction and a second force to the implant in a second direction opposite the first direction when the handle assembly is actuated.
 45. A holder as in claim 44, wherein, upon actuation, a first portion of the implant remains stationary and at least a second portion of the implant move toward or away from the stationary portion.
 46. A holder as in claim 44, wherein the holder assembly is curvilinear.
 47. A holder assembly as in claim 44, wherein the holder assembly includes a lock ring that grabs an inside portion of the implant when the handle assembly is actuated to secure the implant to the holder assembly.
 48. A holder assembly as in claim 44, wherein a distal edge of the holder assembly is wedge-shaped for fitting the holder assembly between a pair of skeletal segments.
 49. An implant for implanting between a pair of skeletal segments, comprising: a first segment; at least one wing attached to the first segment, the wing movable between a collapsed configuration and an expanded configuration wherein the wing can engage a skeletal segment as an anchor when in the expanded configuration; and a second segment removably attached to the first segment, wherein the second segment can be detached from the first segment to disengage the wing from the skeletal segment.
 50. An implant as in claim 49, further comprising a ratchet mechanism that couples the first segment to the second segment, wherein the ratchet mechanism is configured to lock the wing in the expanded configuration 